Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience

BACKGROUND

The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow.

METHODS

This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes.

RESULTS

Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up.

CONCLUSION

Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow

Purpose

This study highlights the advantages and disadvantages of Anterolateral Thigh (ALT) free flap using the brachial artery as the recipient vessel in large posterior defects of the elbow with early mobilization.

Methods

Eight patients with a soft tissue defect on the posterior elbow underwent reconstruction with an ALT free flap. Average age and follow-up were 29.5 years (range, 18-43 years) and 54 months (range, 35-76 months), respectively. All defects were on the posterior side, and brachial arteries on the anterior side were used as the recipient artery in all cases. Four defects were created by tumor excision, four were exposed with hardware after fixation of distal humeral and/or proximal ulna fractures. The dimensions of defects were between 80 and 352 cm2. Cases were evaluated according to function (ROM), complications, tissue quality anticipated from reconstruction and immobilization time after the reconstruction.

Results

All flaps except one survived and met the tissue quality anticipated from this reconstruction. In the bigger flaps, an apparent ugly scar at the donor site was the main problem. The flap on the posterior, and recipient artery on the anterior had no adverse effects on early motion of the elbow. Two cases with fractures had minimal restriction of elbow movement due to post-traumatic stiff elbow. There was one case of partial flap loss after myocardial infarction. After the patient was medically stable, the remaining distal defect was closed with a pedicled radial forearm flap.

Conclusion

ALT free flap has numerous advantages in covering defects at the posterior elbow such as being pliable, thin and durable skin, with a long and reliable pedicle reaching the brachial artery without causing any problem in early motion and surgical reconstruction can be easily completed in the supine position.

Reconstruction of upper extremity soft tissue defects with free flaps

Aim: Many methods have been described in the literature for the reconstruction of upper extremity defects that may occur as a result of various etiological reasons. Among these methods, local or regional flaps are used quite frequently, and most defects can be successfully reconstructed. However, in some large and complex defects, technically more difficult free flap options may be unavoidable. In our study, we present our experience on upper extremity reconstruction with free flaps. Materials and Methods: Between 2015 and 2021, 9 patients (3 Female, 6 Male) underwent upper extremity reconstructions with free flaps. The ages of the patients ranged from 22 to 68 years. Our free flap choices included anterolateral thigh flap in 4 patients, latissimus dorsi free flap in 4 patients, and radial forearm free flap in 1 patient. Defects of patients were including dorsum of the hand in 3 patients, an amputation stump in 1 patient, the dorsum of the hand with the forearm in 2 patients, and the elbow with the forearm in 3 patients. Results: The radial artery was chosen as the recipient artery in all patients. The concomitant vein of the radial artery or the superficial venous system was used as the recipient vein. End-to-end anastomosis was performed in 6 patients and end-to-side anastomosis was performed in 3 patients. Arterial thrombosis was observed in 1 patient and venous thrombosis was observed in 1 patient. All vascular complications occurred in reconstructions with latissimus dorsi free flaps. Both patients were taken to early salvage surgery, the anastomoses were renewed and the flaps were salvaged. No additional complications were observed in other patients. There was no flap loss in our clinical series. Conclusion: Free flaps can be used safely for upper extremity soft tissue reconstructions in appropriate cases. Although it requires technical experience, we believe that perforator-based free flaps are quite advantageous due to minimal donor site problems and can be safely chosen as the first method in suitable patients.